Results:

The following summarizes 11 of the writing group’s suggestions for CICU best practices:

1. All CICUs should monitor for the presence of preventable hospital-acquired infections (HAIs) and multi-drug resistant pathogens and use preventative strategies, including meticulous hand hygiene. All CICUs should use best-practice care bundles to prevent common HAIs, including central line–associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia.
2. Patients in the CICU should undergo routine screening for delirium with either the Intensive Care Delirium Screening Checklist or the Confusion Assessment Method – Intensive Care Unit. Minimizing the use of medications associated with delirium, including benzodiazepines, and implementing early mobilization protocols may reduce the risk of delirium.
3. The use of antipsychotics in the CICU should be restricted to patients with hyperactive delirium who are at risk of harming themselves or others and have a low risk for long QTc-associated arrhythmias.
4. Patients in the CICU requiring mechanical ventilation who remain anxious or agitated after appropriate pain or delirium treatment should be treated with a sedation protocol that targets light sedation (e.g., Richmond Agitation Sedation Scale score of -1 to 0). Daily sedation interruption can be considered in patients requiring deep sedation to facilitate neurological assessments or the suitability for light sedation.
5. The sedative agent should be tailored to the individual patient’s presenting condition, comorbidities, hemodynamics, and perceived duration of mechanical ventilation. It is reasonable to avoid intravenous benzodiazepines as a routine first-line sedative-hypnotic given the risk of delirium in the absence of clear medical indications.
6. In the mechanically ventilated CICU population, the authors suggest that neuromuscular blockade agents should be used in patients with refractory hypoxemia, hypercarbia, dyssynchrony, or target temperature management-associated shivering.
7. When feasible, use a routine tidal volume of 6-10 ml/kg ideal body weight in the CICU, with lower tidal volume (6-8 ml/kg ideal body weight) for patients at high risk of ventilator-associated lung injury or with established acute respiratory distress syndrome.
8. The applied positive end-expiratory pressure (PEEP) level should be tailored to each patient’s underlying pathophysiology and adjusted to achieve oxygenation and hemodynamic targets. Higher PEEP can be considered in patients with left ventricular dysfunction and elevated filling pressures. A lower PEEP may be appropriate for patients with right ventricular dysfunction, pericardial tamponade, constriction, and hypovolemia to prevent hemodynamic instability.
9. Oxygenation in the CICU should be closely monitored with supplemental oxygen titrated to achieve SpO₂ >90% or PaO₂ >60 mm Hg; hyperoxia (PaO₂ >150 mm Hg) should be avoided.
10. High flow nasal cannula or noninvasive positive pressure ventilation (NIPPV) should be used in appropriately selected patients in the CICU with acute respiratory failure to reduce morbidity and mortality and to minimize the need for invasive, endotracheal intubation. NIPPV should be considered after extubation for patients at risk for reintubation.
11. Early mobilization protocols should be routinely incorporated into management plans for patients in the CICU. Eligibility for early mobilization should be assessed daily with a multidisciplinary team, including physician, nursing, and rehabilitation team members. The use of vasoactive agents, mechanical ventilation, intravascular catheters, and mechanical circulatory support devices and altered mental status do not preclude early mobilization.